Provider Demographics
NPI:1730107061
Name:O'BRIEN, MICHAEL KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEVIN
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:60 TEMPLE ST
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2716
Mailing Address - Country:US
Mailing Address - Phone:203-772-0650
Mailing Address - Fax:203-785-9097
Practice Address - Street 1:60 TEMPLE ST
Practice Address - Street 2:SUITE 5A
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2716
Practice Address - Country:US
Practice Address - Phone:203-772-0650
Practice Address - Fax:203-785-9097
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-01-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT035075208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001405150Medicaid
G23517Medicare UPIN
CT001405150Medicaid